PHYSIOTHERAPY IN THE

MANAGEMENT OF DIABETIC
PERIPHERAL NEUROPATHY
Presented By:
AJAKAIYE D.E
POPOOLA F.F
SUPERVISED BY:
DR. ABOLARIN
DR. OSENI
DR. ADEOSUN
DR. OGOR
Outline 2
 INTRODUCTION
 EPIDEMIOLOGY
 PATHOPHYSIOLOGY
 COMPLICATIONS
 MANAGEMENT
 CASE STUDY
 CONCLUSION
 RECOMMENDATION
INTRODUCTION 3

 Diabetic peripheral neuropathy(DPN) is otherwise known as

diabetic peripheral nerve pain and distal polyneuropathy or simply

peripheral neuropathy..

 It is the most common types of diabetic neuropathy , others being

autonomic, proximal and mononeuropathies DN.

DEFINITION 4

 Diabetic peripheral neuropathy is define as the presence of

symptoms and / signs of peripheral nerve dysfunction in people with

diabetes after the exclusion of other causes (Boulton AJ et al;2017).

 5

 It affects nerves leading to the extremities—the feet, legs, hands,

and arms, after they branch off the spinal cord in the lumbar region

(low back) which causes numbness, loss of sensation, and

sometimes pain in these areas.

 6

 About 60% to 70% of all people with diabetes will eventually

develop peripheral neuropathy, although not all suffer pain. Yet this

nerve damage is not inevitable ( Michael D, 2019).

 7

 Studies have shown that people with diabetes can reduce their risk

of developing nerve damage by keeping their blood sugar levels as

close to normal as possible ( Michael D, 2019).

EPIDEMIOLOGY 8
Diabetes (international
diabetic federation)

l ly Af
ba ric
lo a
G
39 million
425 Million 629 million
(2017)
(2017) (2045)

82 million
(2045)
 (World Health Organization, 2019)
EPIDEMIOLOGY CONTD 9

 In another study, the overall prevalence of diabetic peripheral

neuropathy in Africa was 46%.

 Based on the subgroup analysis, the highest prevalence of diabetic

peripheral neuropathy in DM patients was reported in West Africa

at 49.4%
 10

 The lowest was observed in Central Africa at 35.9% .

This discrepancy could be explained by studies using different

diagnostic criteria for diabetic neuropathy, the quality of the health

care service, and the duration and severity of diabetes (Sanny K, 2017)
ETIOLOGY/RISK FACTORS 11

• Prolong elevated level of blood sugar (Poor glycemic control)

Other factors are;

Hypertension

Advance age

Life style factors (smoking and alcohol)

SIGNS AND SYMPTOMS 12

SIGNS

Diminished vibratory perception

Decreased knee and ankle reflex

Reduced protective sensation such as pressure, hot and cold, pain

Diminished ability to sense position of toes and feet

 13
 SYMPTOMS

 Numbness loss of feeling, prickling, tingling

 Aching pain
 Burning pain
 Lancinating pain
 Allodynia
PATHOPHYSIOLOGY 14

 Hyperglycemia

 Atherosclerosis

 Vasoconstriction
PATHOPHYSIOLOGY CONTD 15
DIAGNOSIS
16

 Patient’s history
 Blood sugar test
 Monofilament test
 Sensation test
 Electromyography
BLOOD SUGAR TEST 17
RESULTS A1C TEST FASTING GLUCOSE RANDOM
BLOOD TOLERANCE BLOOD
SUGAR TEST TEST SUGAR TEST
DIABETES 6.5% or above 126mg/dl or 200mg/dl or 200mg/dl or
above above above
PRE-DIABETES 5.7-6.4% 100-125mg/dl 140-199mg/dl
NORMAL Below 5.7% 99mg/dl or 140mg/dl or
below below
DIFFERENTIAL DIAGNOSIS
18

 Alcohol neuropathy

 Chronic inflammatory demyelinating neuropathy

 Vasculitis
COMPLICATIONS
19
 Pain

 Altered sensation
 Muscular atrophy/weakness
 Fall

 Infection (gangrenous digits)

 Sometimes, might lead to amputation
MEDICAL MANAGEMENT
20
 It primarily involves managing the cause, diabetes (blood glucose
control).
 Anti-diabetic therapy with insulin or oral agents can be used. Also,
anti-convulsants, analgesics, narcotics can help relieve the pain.
PHYSIOTHERAPY MANAGEMENT
21
Regular exercise can help reduce neuropathic pain and help control blood
sugar levels. Some of the physiotherapy interventions focus on:

 Relief of pain

 Muscle strengthening

 Flexibility training

 Balance training

 Gait training
CASE STUDY
22
 A 55 year old right handed dominant male who presented to this
facility on account of pain in the left leg and difficulty in walking.
 Patient(Pt) reported that the pain started about 6 months ago after
noticing a mild swelling in the left distal leg. He went to the general
hospital, there he was placed on antibiotics. With no improvement in
symptoms (pain + swelling), he came to this facility and pus was
drained from the swollen aspect of the leg.
CASE STUDY
23
 Pt was advised to go for a diabetes screening of which he was
diagnosed positive (December, 2020).

 Following discharge, Pt continued his therapy and dressing of the

draining site at a private clinic and more site on the anterior aspect of
the foot were opened to drain the remaining pus.

 However, after some days Pt noticed he could not move his toes +
persistent pain after which he started ambulating with Zimmers’
frame of which was progressed to a walking stick.
CASE STUDY 24
 He was then referred for physiotherapy clinic of this facility.
 PMhx: Nil hx of HTN, PUD, Blood transfusion; a known DM (4/12
ago)
 PSHx: nil
 Dghx : Tramadol, D148
CASE STUDY 25
 F/Shx:Muslim, Married with 3 children in a monogamous setting, a
police officer still in service, who resides in a bungalow. Regular
tobacco smoker ; takes alcohol occasionally.
 O/E: A middle-aged healthy looking man who walked into the
treatment cubicle aided with a walking stick, with a high-stepping
gait, loss of toe-off in the swing phase, afebrile to touch, acyanosed,
not in any obvious respiratory distress.
CASE STUDY
26
 Vitals:
 B.P: 100/70mmHg

 H&N

-Nil Facial asymmetry

-Nil audiovisual impairment
-ROM full and pain free in all range
CASE STUDY
27
 T& A

-No chest/spinal deformity

-Abdomen is full and moves with respiration
-Bulging at the left aspect of the abdomen
CASE STUDY
28
 Upper Limb
-GMP is 4+ bilaterally
-Muscle bulk is preserved bilaterally
-Muscle tone is normal bilaterally
-Grip strength is excellent bilaterally
-Sensation is intact bilaterally
CASE STUDY
29
Lower Limb Right Left

Muscle bulk Preserved Preserved

Muscle tone Normal Normal

Sensation Intact Diffused @ plantar

surface of leg (L5)

Proprioception Intact Intact

CASE STUDY
30
Lower Limb Right Left

GMP 4+ 3+

TA Tightness Nil Mild

LLD Apparent: 101.5cm Apparent:103.5cm

Real: 92cm Real: 94cm
Swelling @ the ankle 20.5cm 23cm
(10cm from middle
malleoli)
CASE STUDY
31
Lower Limb (Muscle Right Left
Chart)
Hip Flexors/Extensors 4/4- 3/3

Hip Abd/Add 4/4 3/3

Knee Flex/Ext 3+/4 3/3+

Ankle 3+/3+ 0/1

Dorsiflexors/Plantar
CASE STUDY
32

Functional Assessment
 Pain limits activites e.g praying, going to work
 Unable to maintain balance when standing
 Unable to walk long distance without walking stick
CASE STUDY
33

Analysis of findings
 Pain @ the left leg on passive dorsiflexion/eversion/inversion (10/10-
NPRS)
 Limb Length Discrepancy (left>right-2cm)
 Weak dorsiflexors
 Altered sensation @ plantar surface of the left leg (L5)
 Impaired balance
CASE STUDY
34
Pain+ Impaired mobility 2° Diabetic Neuropathy complicated
by pyomysitis
 Plan

- To relieve pain(short term goal)

-To reduce swelling(short term goal)

-To strengthen weak muscles

-To improve balance and gait when walking

CASE STUDY
35
Sensory retraining
-

-To improve the patient’s quality of life.

Treatment Sessions
-Counselling on condition and lifestyle modification advice
-Cryotherapy to the left leg x5mins (week 1)
-TENS to the painful site x10mins (week 1)
-STM using fastum gel to painful areas (week 1)
-Tactile stimulation to the left leg (week 1)
-Passive ankle mobilization (week 1) -Static quadriceps contraction
x10shold,10 reps,10 sets (week 2)
CASE STUDY
36

-One leg stance x 50reps, 5 sets (week 2)

-Muscle strengthening of left quadriceps, hamstrings, hip abductors/

adductors using 1.5 kg sandbag (week 2), then 2.5kg sandbag(week 3),
3.0kg sandbag (week 4).

-Standing on the toes/heel x50 reps (week 4)

 Strengthening exs to the bilateral LL using multigym (week 5)
 Balance/ Gait retraining (week 6)
CASE STUDY
37

MINI -REVIEW (WEEK 4)

 Pain @ the left leg on passive dorsiflexion/eversion/inversion (6/10-
NPRS)
 Improved sensation @ plantar surface of foot (deficit areas at the toes
and lateral plantar area)
 Increased muscle strength @ the left LL; GMP 4 (Hip Flex/Ext; Knee
Flex/Ext)
CASE STUDY
38

FINAL REVIEW (WEEK 7)

 FUNCTIONAL ASSESSMENT

-Able to walk for a prolonged time without pain

- Resumed work (as a police officer)
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